Download Brian Palmer, DDS. Kansas City, Missouri, USA

Breastfeeding
and
Frenulums
Brian Palmer, DDS.
Kansas City, Missouri, USA
#1 of 84 slides
December, 2003
Warning
This presentation has slides of cadaver
dissections and may not be suitable for
viewing by all persons. This presentation
was designed for pediatricians, lactation
consultants and other health care
professionals who consult with parents
regarding the issue of breastfeeding and
tight frenulums.
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All of the following are
correct spellings:
Frenulum, frenulums, frenula
Frenum, frenums, frena
Frenotomy, frenectomy
Tongue-tie, tongue-tied
All spellings can be found in medical dictionaries
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Consequences of Frenulums
on Breastfeeding
• Nipple trauma and pain.
- Compression of breast from gum pad instead of tongue.
• Inefficient, inadequate suckling.
- Limited action of tongue / poor wave motion.
- Tongue unable to compress the breast effectively.
• Poor seal.
- Tight labial frenum(s) does not allow flanging of lip(s).
• Lengthy feedings.
• Failure to thrive.
• Infant often switched to bottle and pacifiers.
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Surgical Indications
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• Breastfeeding difficulties
• Dental problems
• Speech impediments
• Medical problems
– Indigestion
– Snoring and sleep apnea
– SIDS (?)
• Personal / Social reasons
– Licking ice-cream cones
– Kissing
Incidence of ankyloglossia
ƒ 4.8%
ƒ Conclusions:
ƒ Tongue-tie is common.
ƒ It may affect breastfeeding adversely.
Messner AH, Ankyloglossia: incidence and associated feeding
difficulties, Arch Otolaryngol Neck Surg 2000 Jan;126(1):36-9.
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7 Demonstrates position and action of tongue during breastfeeding. (Woolridge)
8 Previous picture altered in left picture to illustrate an infant who is tongue-tied.
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Illustration from Ros Escott article, Positioning, Attachment
and Milk Transfer, Breastfeeding Review, 1989, p.35.
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Previous picture altered to illustrate impact of tight frenum.
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Edmund S. Crelin, Ph.D., D.Sc.
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Faculty member at Yale, 1951-1988.
Professor of Anatomy, Dept. of Surgery.
Chairman: Human Growth & Development.
Author of 168 research articles.
Author of 3 books..
Author of 5 CIBA Clinical Symposia.
3 awards at Yale as “outstanding teacher”.
Soft palate
Epiglottis
The epiglottis is in direct contact with the soft palate. “The
tongue is located entirely within the oral cavity”. (Crelin)
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Soft palate
Epiglottis
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Atlas picture demonstrating similar relationship
of epiglottis and soft palate. (Rohen/Yokocki)
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Adult chimpanzee (Crelin).
Note soft palate / epiglottis relationship.
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Frontal view of fetus cadaver. Note separation of lips.
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Note forward position of tongue.
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Mid-sagittal dissection of fetus cadaver.
Eustachian tube
Bubble palate
Soft palate
Tip of
tongue
Tooth bud in
mandible
Epiglottis
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Cadaver dissection demonstrating habitual tongue posture
and relationship between the soft palate and epiglottis.
Crelin ES. Development of the
Upper Respiratory System, Clinical
Symposia, Vol. 28, No. 3, 1976.
During the act of breastfeeding, Dr. Crelin states the larynx can
be elevated so that the epiglottis can slide up behind the soft
palate to lock the larynx into the nasopharynx. This allows the
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infant to both swallow and breathe at the same time.
Crelin ES. Development of the Upper
Respiratory System, Clinical
Symposia, Vol. 28, No. 3, 1976
Faucium channel
View looking into the mouth
to illustrate the interlocking of
the soft palate and epiglottis.
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Soft palate
Epiglottis
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Cadaver dissection showing enclosed air tube / airway.
Possible reasons for the natural
anterior positioning of the tongue.
• To allow the infant to breastfeed
immediately after birth - ie - allows the
natural extension of the tongue to allow for
the compression of the lactiferous sinus area
and the total length of the breast.
• Allow the infant to naturally breathe and
swallow at the same time without learning a
complicated protective mechanism.
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“Maturational descent of the epiglottis,
found to occur between 4 and 6 months
of age, is verified by cineradiography.”
“This period, interestingly coincides with the
peak incidence of SIDS, which similarly occurs
at 3 to 5 months of age.”
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Sasaki CT, Crelin E,S et al. Postnatal Descent of the Epiglottis in
Man, March 1977, Arch Otolaryngol, Vol. 103, 169-171.
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As the epiglottis descends, the tip of the tongue
falls back into the mouth to an adult position.
Close view of adult dissection
demonstrating separation
between epiglottis and soft
palate.
Soft palate
Tongue
Epiglottis
Note that the posterior 1/3 of
the tongue is now the anterior
wall of the oropharynx.
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This adult individual
may have died from
OSA. Note blockage of
airway by soft palate
and base of tongue.
Also note retruded
(pushed back) Class II
mandible (chin).
(Grant’s Atlas)
If this had been an
illustration of an infant,
he/she may have died
from SIDS.
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With the descent of the
epiglottis a common area is
created where both food and
air can mix.
This descent also allows
humans to produce a greater
variety of sounds than all
other air-breathing forms.
(Crelin)
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Reason for pain/poor feeds
• Gum pad traumatizes breast. Tongue
cannot cushion blow from pad.
• Tongue unable to compress full
length of breast.
• Tight labial frenum does not allow
flanging of the lip(s).
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ET
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Tight frenulums and bottle feeding can alter a natural swallow,
drive the tongue back and separate the epiglottis / soft palate.
Lingual frenulums
RARELY
go away by themselves.
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Ankyloglossia Symptoms
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Heart shape of tongue when raised.
Cannot extend tongue out to a point.
Tongue curves down when extended.
Usually leads to a deviate swallow.
Possible speech problems.
May have trouble swallowing pills.
May have digestive problems.
Difficulty in licking ice-cream cones.
Difficulty in kissing.
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New born with tight frenum and heart shaped tongue. (Dr. Notestine)
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3 month old who was weaned because of breastfeeding difficulties.
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“Tongue lifter” - used to be quite common in birthing surgical packs.
36 Age 4 months - Note lesion on frenum caused by teeth.
37 (1976) Age 3 years - Frenum already causing teeth to rotate.
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Tight thick frenum with classical heart shape of tongue. (Dr.Notestine)
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(1996) Age - 6 1/2 years.
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Young adult who is tongue-tied. Note tongue-bar!
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Retired MD - Tongue curls down and cannot extend past lip.
Clinical Reasons
for a frenotomy
• Painful attachment at the breast.
• Nipple trauma / nipple breakdown.
• Failure to thrive / poor milk transfer.
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Tight labial frenums also
impact breastfeeding because they can
alter the infant’s ability to latch-on.
They DO NOT go away by
themselves either.
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Thick frenum causing diastema - probably interfered with breastfeeding.
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He could not elevate lip well.
Treatment Options
• Frenotomy
– No anesthetic needed
– No suturing
• Frenectomy
– Local or general anesthetic used
– Sutures placed
• Z-plasty
– More complex
– Sutures placed
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These options discussed more in other presentation on frenulums on this website.
Consequences of
not treating
tight frenulums.
Case reports:
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Case 1
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Age 4 (1992)
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Age 4 - Tight frenulum - note pull on inside of lower jaw.
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A tight frenulum caused this tongue-thrust.
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Age 4 - The tongue-thrust caused this open bite.
Comparison of
cause and effect.
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Tongue-thrust
created this adult’s
open bite
malocclusion.
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Tongue-thrust created
this adult’s open bite
malocclusion and
gingival recession.
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Case 2
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57 Breastfed boy showing malocclusion with very crowded teeth.
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Even though youngster was breastfeed, he still developed a high palate.
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Reason for malocclusion and high palate - he is tongue-tied!
Case 3
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Patient in early 30s. Is severely tongue-tied.
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Tongue fully extended - note grove on top of tongue.
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Force of tongue-thrust has actually rocked lower tooth
loose. Patient eventually lost all 4 lower incisors.
Case 4
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Patient - Age 40.
She had significant
gastric distress,
bloating and gas
build up.
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She was significantly tongue-tied.
67 Post Z-plasty healing. Note how high she can now elevate tongue.
She can now extend
tongue out quite far.
She is now off all
medications that she
had been on all her life
for gastric distress, etc.
Why? She can now
chew better and does
not swallow air like
she used to.
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Case 6
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Down’s Syndrome Case - Tongue Retaining Device.
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Frenectomy and appliance improved life.
Case 7
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72 Tight frenulum on patient in 60s with severe sleep apnea.
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Same patient trying to elevate tongue as high as possible.
Demonstrates tight frenum and large tongue (macroglossia).
74 Patient MUST sleep with CPAP every night for his sleep apnea
Challenges:
• #1 reason surgery is not performed
- fear of litigation.
• Procedures not taught in medical or dental
schools.
• Not much literature on subject.
• Only one book published on the subject.
• Myths / misinformation abound on the topic.
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Based on 30 years of clinical observation I
have sufficient documentation to state that:
• Frenulums do not go away by
themselves.
• Frenulums can have significant
consequences on oral cavity
development and total health.
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Test yourself:
Place and hold the tip of your
tongue into the gum tissue
below the lower front teeth - try
to swallow, eat or talk with the
tongue held in this position.
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For those who cannot feel a
difference or who adamantly oppose
recommending frenotomies or
frenectomies, I will send someone
over to your office and suture your
tongue to the floor of your mouth.
After one week you will understand
the significance of a tight frenum! :-)
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Recommendations:
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• Exam all newborns for tight frenulums.
• Do as much of a frenotomy that will allow
the infant to breastfeed successfully.
• Inform parent(s) that further surgery may be
needed at a later time.
• For the overall health of the infant, if you
are not comfortable doing the procedure,
please refer to someone else who is.
• Side effects are minimal, benefits are
significant.
Recommendations cont’d:
• Courses need to be taught in medical and dental
schools on how to perform the various surgeries.
Lasers should help simplify the more complicated
procedures.
• Encourage others do more research on the impact
that tight frenulums have on the development of
the oral cavity and airway.
• Insurance codes need to be developed that
recognize the various degrees of difficulty of the
different procedures and reimburse for services
accordingly.
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Concerns:
• Unqualified providers will try to perform
the surgeries and get bad results. Negative
press will discourage others from doing a
very beneficial service.
• The fee for the service needs to fit the
degree of difficulty of the procedure - a
frenotomy ‘snip’ does not warrant the same
fee as a much more complicated Z-plasty.
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Disclosure:
I personally do not do any of the surgeries. I refer my patients
to a very qualified oral surgeon who understands the importance
of releasing tight frenums. Point of interest: His mother is a
retired Pediatrician who routinely did frenotomies when she was
in practice.
Another point of interest: In the past, Midwives used to
clip tight frenulums on newborns with their finger nail.
Some would have one long nail for doing the clipping.
Although unsanitary by present standards, it was effective.
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“Knowledge is most meaningful
when shared with others.”
Brian Palmer, DDS
Please share this presentation with others.
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Presentation prepared by:
Brian Palmer, D.D.S.
Kansas City, Missouri, USA
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A condensed version of this presentation was given at a
Pediatric conference in Kansas City on November 21, 2003.